1
PHYSIOLOGICAL ADAPTATION NUTRITION QUESTIONS WITH
WELL EXPALAINED RATIONALES
1.For a client receiving total parenteral nutrition (TPN), the nurse reviews the
following lab values: Glucose = 72 mg/dL Chloride =98 mEq/L Sodium =
138 mEq/L Potassium = 3.0 mEq/L
Based on this assessment, which nursing action is appropriate?
a. Discontinue TPN administration.
b. Notify physician and obtain order for potassium supplement.
c. Administer IV glucose immediately.
d. Check client vital signs immediately.
The normal plasma potassium level is 3.5-5.5mEq/L. This clients potassium is low and needs
replacement. Options #1, #3, and #4 do not address the problems.
2. Which nursing action is most appropriate for a 2-month-old infant with reflux?
a. Hold the next feeding.
b. Teach the mother CPR.
c. Maintain normal feeding schedule.
d. Elevate the head of the bed.
An infant with reflux should be maintained in an upright position. The head of the bed
should be raised at a 30- degree angle. Option #1 may not be necessary, if positioning is
effective. Option #2 is an action for the mother versus the infant. Option #3 is incorrect
because the clients feedings should be changed to small volume, frequent feedings.
3.A client is taking metoclopramide hydrochloride (Reglan) orally for nausea secondary
to chemotherapy. In reference to the timing of the medication, when would the nurse
instruct the client to take the medication?
a. With each meal
b. Thirty minutes before meals
c. One hour after each meal
d. At the same time each day
Since metaclopramide facilitates gastric emptying, it must be taken before meals. Options
#1 and #3 do not promote optimum effects of the medication. Option #4 is incorrect
because the time of administration should be changed to give with the clients meals.
4.Before breakfast, a 9-year-old child with juvenile diabetes (Type I) passed out on
the living room floor after taking his morning insulin dose. The nurses best response
is based on which concept?
a. A child with a viral infection can have hypoglycemia,
b. Children with diabetes may act out to get attention.
c. Insulin shouldnt be taken until 30-60 minutes after breakfast.
d. The morning dose caused hypoglycemia before the child ate.
When children become distracted and fail to eat after a dose of insulin, hypoglycemia can easily
occur. Option #1 is incorrect because viral infections result in hyperglycemia and there is no
indication the child has an infection.
Option #2 may be correct, but it would be a mistake to assume so in this situation. Option #3
,2
5.A 3-month-old infant is scheduled for a barium swallow in the morning. Prior to
the procedure, the most appropriate nursing action would be to:
a. offer the infant only clear liquids.
b. make the infant NPO for 3 hours.
c. feed the infant regular formula.
d. maintain NPO for 6 hours.
An infant should be NPO 3 hours prior to the procedure. Options #1 and #3 are
inappropriate. Option #4 is incorrect because it is not necessary for an infant to be NPO for
6 hours.
6.Which nursing action is most appropriate for a client receiving a tube feeding around the
clock?
a. Rinse the bag and change the formula every 4 hours.
b. Rinse the bag and change the formula every shift.
c. Change the bag and formula every shift.
d. Rinse the bag and change the formula every 2 hours.
Research indicates there is an increased growth of organisms after four hours. Options . #2
and #3 are inappropriate due to increased organism growth. Option #4 is not a necessary
action to maintain asepsis.
7. A nurse is obtaining a health history from a mother of a child with failure to thrive. Which
assessment would
, 3
provide the most pertinent data?
a. Weight and height
b. Urine output
c. Type of feedings
d. Mother-child interactions
This provides the most pertinent data in assessing actual growth. Option #2 is inappropriate
for this situation. Options #3 and #4 are important assessments but are not a priority to
Option #1.
8. What instructions would a nurse give a diabetic client who has been vomiting for 24
hours and is concerned about blood glucose levels?
a. Take only half of the regular insulin dose.
b. Attempt to maintain a regular diabetic diet.
c. Limit intake of sweets and sugar.
d. Drink liquids as often as possible.
Diabetic ketoacidosis is frequently associated with dehydration. Fluids should be
encouraged. Option #1 is incorrect because a diabetic should alter the dose according to
serial glucose checks. Option #2 is incorrect because the client is not tolerating PO foods.
Option #3 is incorrect because sweets can be used as calories in this situation.
9.What type of foods would be best for an 8-year-old receiving chemotherapy?
a. A diet high in nutrients
b. Hot and spicy foods
c. Small and frequent meals
d. Foods on a regular schedule to promote a routine
Offering small and frequent meals will help prevent nausea and enable the client to eat
adequate amounts. Option #1 is important but is not a priority to Option #3. Option #2 may
promote vomiting. Option #4 does not provide adjustments for the clients illness.
Which of the following would be the best plan for prevention of constipation
10.
during the first trimester of pregnancy?
a. Take mineral oil every morning.
b. Increase bulk and fiber in the diet.
c. Take a mild laxative as needed.
d. Decrease fluid intake.
This will assist in preventing constipation. Options #1 and #3 are incorrect for the pregnant
woman. Option #4 will lead to more constipation.
11.Which foods indicate the most appropriate breakfast choices for a young adult female
client, 5'7" tall, weighing 257 pounds, who is seeking weight loss assistance?
a. Applesauce, Cream of Wheat, toast
b. Scrambled eggs and toast, one slice of bacon
c. 1 glass of grapefruit juice
d. Bagel with 2 ounces of cream cheese and a banana
A breakfast with some substance wont leave her feeling hungry most of the morning.
Options #2 and #4 have high fat content which is inappropriate for weight loss. Option #3
doesnt provide a balance of nutrients and may leave the client feeling very hungry before
lunch.
PHYSIOLOGICAL ADAPTATION NUTRITION QUESTIONS WITH
WELL EXPALAINED RATIONALES
1.For a client receiving total parenteral nutrition (TPN), the nurse reviews the
following lab values: Glucose = 72 mg/dL Chloride =98 mEq/L Sodium =
138 mEq/L Potassium = 3.0 mEq/L
Based on this assessment, which nursing action is appropriate?
a. Discontinue TPN administration.
b. Notify physician and obtain order for potassium supplement.
c. Administer IV glucose immediately.
d. Check client vital signs immediately.
The normal plasma potassium level is 3.5-5.5mEq/L. This clients potassium is low and needs
replacement. Options #1, #3, and #4 do not address the problems.
2. Which nursing action is most appropriate for a 2-month-old infant with reflux?
a. Hold the next feeding.
b. Teach the mother CPR.
c. Maintain normal feeding schedule.
d. Elevate the head of the bed.
An infant with reflux should be maintained in an upright position. The head of the bed
should be raised at a 30- degree angle. Option #1 may not be necessary, if positioning is
effective. Option #2 is an action for the mother versus the infant. Option #3 is incorrect
because the clients feedings should be changed to small volume, frequent feedings.
3.A client is taking metoclopramide hydrochloride (Reglan) orally for nausea secondary
to chemotherapy. In reference to the timing of the medication, when would the nurse
instruct the client to take the medication?
a. With each meal
b. Thirty minutes before meals
c. One hour after each meal
d. At the same time each day
Since metaclopramide facilitates gastric emptying, it must be taken before meals. Options
#1 and #3 do not promote optimum effects of the medication. Option #4 is incorrect
because the time of administration should be changed to give with the clients meals.
4.Before breakfast, a 9-year-old child with juvenile diabetes (Type I) passed out on
the living room floor after taking his morning insulin dose. The nurses best response
is based on which concept?
a. A child with a viral infection can have hypoglycemia,
b. Children with diabetes may act out to get attention.
c. Insulin shouldnt be taken until 30-60 minutes after breakfast.
d. The morning dose caused hypoglycemia before the child ate.
When children become distracted and fail to eat after a dose of insulin, hypoglycemia can easily
occur. Option #1 is incorrect because viral infections result in hyperglycemia and there is no
indication the child has an infection.
Option #2 may be correct, but it would be a mistake to assume so in this situation. Option #3
,2
5.A 3-month-old infant is scheduled for a barium swallow in the morning. Prior to
the procedure, the most appropriate nursing action would be to:
a. offer the infant only clear liquids.
b. make the infant NPO for 3 hours.
c. feed the infant regular formula.
d. maintain NPO for 6 hours.
An infant should be NPO 3 hours prior to the procedure. Options #1 and #3 are
inappropriate. Option #4 is incorrect because it is not necessary for an infant to be NPO for
6 hours.
6.Which nursing action is most appropriate for a client receiving a tube feeding around the
clock?
a. Rinse the bag and change the formula every 4 hours.
b. Rinse the bag and change the formula every shift.
c. Change the bag and formula every shift.
d. Rinse the bag and change the formula every 2 hours.
Research indicates there is an increased growth of organisms after four hours. Options . #2
and #3 are inappropriate due to increased organism growth. Option #4 is not a necessary
action to maintain asepsis.
7. A nurse is obtaining a health history from a mother of a child with failure to thrive. Which
assessment would
, 3
provide the most pertinent data?
a. Weight and height
b. Urine output
c. Type of feedings
d. Mother-child interactions
This provides the most pertinent data in assessing actual growth. Option #2 is inappropriate
for this situation. Options #3 and #4 are important assessments but are not a priority to
Option #1.
8. What instructions would a nurse give a diabetic client who has been vomiting for 24
hours and is concerned about blood glucose levels?
a. Take only half of the regular insulin dose.
b. Attempt to maintain a regular diabetic diet.
c. Limit intake of sweets and sugar.
d. Drink liquids as often as possible.
Diabetic ketoacidosis is frequently associated with dehydration. Fluids should be
encouraged. Option #1 is incorrect because a diabetic should alter the dose according to
serial glucose checks. Option #2 is incorrect because the client is not tolerating PO foods.
Option #3 is incorrect because sweets can be used as calories in this situation.
9.What type of foods would be best for an 8-year-old receiving chemotherapy?
a. A diet high in nutrients
b. Hot and spicy foods
c. Small and frequent meals
d. Foods on a regular schedule to promote a routine
Offering small and frequent meals will help prevent nausea and enable the client to eat
adequate amounts. Option #1 is important but is not a priority to Option #3. Option #2 may
promote vomiting. Option #4 does not provide adjustments for the clients illness.
Which of the following would be the best plan for prevention of constipation
10.
during the first trimester of pregnancy?
a. Take mineral oil every morning.
b. Increase bulk and fiber in the diet.
c. Take a mild laxative as needed.
d. Decrease fluid intake.
This will assist in preventing constipation. Options #1 and #3 are incorrect for the pregnant
woman. Option #4 will lead to more constipation.
11.Which foods indicate the most appropriate breakfast choices for a young adult female
client, 5'7" tall, weighing 257 pounds, who is seeking weight loss assistance?
a. Applesauce, Cream of Wheat, toast
b. Scrambled eggs and toast, one slice of bacon
c. 1 glass of grapefruit juice
d. Bagel with 2 ounces of cream cheese and a banana
A breakfast with some substance wont leave her feeling hungry most of the morning.
Options #2 and #4 have high fat content which is inappropriate for weight loss. Option #3
doesnt provide a balance of nutrients and may leave the client feeling very hungry before
lunch.
